A major shortage of one of the most widely used hospital antibiotics is putting patients at risk, doctors have warned.

There is an international shortage of of piperacillin-tazobactam, an
antibiotic and antibacterial combination drug known by the trade name
Tazocin, which is usually used intravenously in intensive care. It is
also used to treat a wide variety of conditions including cystic
fibrosis, pneumonia, urinary tract infections, diabetic foot infections
and neutropenic sepsis – a life-threatening condition that can arise in
those receiving anti-cancer treatment.

The document also points out that the use of other drug combinations
could increase the workload for doctors and nurses, as some of them
require more frequent doses and increased monitoring. “Regrettably there
is no other feasible solution at present,” it notes.

Philip Howard, Royal Pharmaceutical Society spokesman on antimicrobial
resistance, said that an explosion at a Chinese factory that produced
raw materials for the medication had caused the problems. Howard said
the UK had experienced supply constraints since March this year.

Hospitals in
the UK have been urged to restrict their use of the drug in order to
conserve stocks. “This is one of the more serious shortages that the NHS
has had to face,” Howard said, although he added there were enough
supplies of other drugs for patients to get the antibiotics they needed.

Documents approved by the Department of Health and Public Health England dated 24 April, seen by the Observer,
advise that the use of piperacillin-tazobactam be restricted to severe
cases of sepsis and ventilator-acquired pneumonia, although some doctors
fear that if the shortage lasts then these patients could also be
affected. Doctors wanting to use the medication for other cases must get
approval.

A doctor who works at a hospital in East Anglia, who asked to remain
anonymous, said he was advised of the piperacillin-tazobactam shortage
by the pharmacy team at his NHS trust
on 18 May in an email stating “we will not be able to obtain any
further stock in the foreseeable future once we have used up all our
current stock”.

The doctor said he believed patients were being put at risk by the
shortage. “Every hospital in this country would use it,” he said. “[If
you look] at the grades of antibiotics we have,
[piperacillin-tazobactam] is probably the second rung from the top. It
is not quite the last resort, but it is almost.”

He said many of the options doctors were having to use were less
powerful or could cause side effects such as kidney damage. “Patients
are either having prolonged stays on these courses of antibiotics, or
even worse, they are not actually even responding,” he added.

In such cases, he said, doctors were increasingly left having to deploy
the last line of defence – an antibiotic known as meropenem, part of a
group of antibiotics known as carbapenems. But resistance to such drugs
is a growing problem,
and doctors are already advised to limit their use. A microbiologist at
a hospital in England, speaking on condition of anonymity, said
meropenem was being used more often than he would like, while critical
shortages had also been encountered for other drugs.

In the case of one antibiotic called ceftriaxone, which is used as the first line of treatment for meningitis, the Observer has
seen a memo from his NHS trust to staff which said it expected to
exhaust all its supplies of the drug within the next few days.

The microbiologist added that the use of antibiotics known as
cephalosporins, which includes ceftriaxone, had previously been reduced
in the UK to help reduce the threat of the dangerous superbug C
difficile. Any rise in use of the drugs, he said, could increase the
risk of such infections.

The cost of piperacillin-tazobactam and other drugs had shot up, the
microbiologist added, while the workload for microbiologists had also
increased, due to the number of calls from doctors and emergency
meetings to discuss shortages.

In another document seen by the Observer, the Department of Health acknowledged that the shortage of piperacillin-tazobactam could cause problems with supplies of other drugs –
a situation Howard also admitted was possible. He added that recent
data did not show a significant rise in the use of meropenem.

The Department of Health said the piperacillin-tazobactam shortage was a
global issue and that more supplies should be available this summer.
“In the interim period we are working with the pharmaceutical industry
and NHS to make sure supplies of alternative antibiotics are available
and have issued guidance about appropriate alternative treatment
options,” it said.

Andrew Seaton, chair of the SAPG, said they did not advise health boards
to increase the use of cephalosporins, except in certain cases, due to
concerns over a possible increase in C difficile infection. He also
pointed out that use of piperacillin-tazobactam and meropenem had been
low before the shortage, and described gentamicin as a cornerstone of
the SAPG approach, saying that there was strong guidance for its safe
use..

But he raised concerns about unreliable supply chains for important
medicines. “Drug shortages in general have become a thorn in our side,”
he said. “I am thinking particularly of drugs that we would like to use
as alternatives to, say, piperacillin-tazobactam and meropenem or the
carbapenem antibiotics.”

But Seaton said he would describe the situation as an inconvenience
rather than a crisis. “There are always alternatives to this
antibiotic,” he said.

The latter also suggested the shortage might offer a silver lining,
presenting a chance to improve control on how the medication is used to
reduce the likelihood of resistance.

According to Howard, the factory in China was now back in full
production, but it might take months before the global supply chain
recovered completely.

Ultimately, said Howard, action needed to be taken to avoid a repeat
situation in the future. “We need to ensure that we use a broader range
of antibiotics in our hospitals, so that if there is a global supply
problem, it doesn’t have such a large impact,” he said.